Raw X12 — CIN MH61339C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2002*|*00501*564972607*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2002*972607*X*005010X279A1~ST*270*2607*005010X279A1~BHT*0022*13*202608122002000001*20260812*2002~HL*1**20*1~NM1*PR*2*NYSDOH*****PI*EMEDNY~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~PRV*PE*PXC*251B00000X~HL*3*2*22*0~TRN*1*202608122002000001*00000000ND~NM1*IL*1******MI*MH61339C~EQ*30~DTP*291*D8*20260813~SE*13*2607~GE*1*972607~IEA*1*564972607~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533386630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160248*533386630*X*005010X279A1~ST*271*533386630*005010X279A1~BHT*0022*11*202608122002000001*20260812*160248~HL*1**20*1~NM1*PR*2*NYSDOH*****FI*141797357~PER*IC*EMEDNY PROVIDER SERVICES*TE*8003439000*UR*www.emedny.org~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~HL*3*2*22*0~TRN*2*202608122002000001*00000000ND~NM1*IL*1*RODRIGUEZ*BRAULIO****MI*MH61339C~N3*92 TAPSCOTT                   2F~N4*BROOKLYN*NY*11212~DMG*D8*19610207*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~LS*2120~NM1*Y2*2*VNS CHOICE PLUS M/M MAP*****PI*YN~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8669867691~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*W*IND*CQ~LS*2120~NM1*Y2*2*METRO CARE MANAGEMENT LLC*****XX*1922565118~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*6P*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*1Q91T70JA28~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*533386630~GE*1*533386630~IEA*1*533386630~